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Protocol for Lithium

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Step 1: First obtain a complete history (to confirm that lithium is indicated and suitable, there is no contraindication, identify whether the patient is taking any medications that interact with lithium, likely to adhere to treatment and the protocol)

Step 2: Physical examination especially blood pressure, pulse, weight, BMI, and thyroid examination

Step 3: Laboratory investigations especially TFTs, eGFR, ECG if needed, and in women of childbearing age, a pregnancy test. Serum calcium is also desirable.

Step 4: Education of the patient about the effects, side effects, the need for strict adherence, the risk of toxicity, signs of toxicity, and conditions that increase the risk of toxicity (in a way that generates a realistic and balanced view of the risks and advantages). Provide written materials Step 5: Start lithium OD200mg or 400mg. Aim for a plasma level of 0.4 to 0.8 mmol/L initially.

Step 6: Check plasma level after a week, then every two weeks until the plasma level is stable (target levels of about 0.4-0.8 mmol/dl). Step 7: If there is a suboptimal response, target a plasma level of up to 1mmol/L. Once a steady-state has been achieved, check every 6 weeks for some time. If no serious issues arise early then, check plasma lithium every 6 months

Step 8: Monitor for side effects history(esp. weight gain and fatigue) and lab investigations( Serum calcium, TFTs, and RFTs including eGFR) every six months.

Step 9: When planning to stop lithium, taper off gradually at a rate not more than 0.2mmol/L (plasma level)weekly.
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